Health Connections

For Physicians

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

Try to resolve open patient cases;

Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);

Send a letter to patients that have been seen within the past year notifying them of the practice closure;

Public Health Grand Rounds

All programs complement the clinical care of providers. By the end of the program, patients will have learned how to set goals to improve their health and lifestyle, manage their symptoms and medication, work with their health care team, talk with family and doctors, relax, eat well and handle difficult emotions. By gaining these skills, patients will become activated and engaged in their care. Healthcare providers will receive feedback on the status of any patient referrals.

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

Try to resolve open patient cases;

Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);

Send a letter to patients that have been seen within the past year notifying them of the practice closure;

The Rhode Island State-Supplied Vaccine program provides vaccine to healthcare providers to immunize people of all ages. A table with details about these vaccines, including their age indications, is available for healthcare providers.

Additionally, a series of immunization requirements are in place in Rhode Island to ensure that healthcare providers are properly immunized.

What you should do

Enroll in the State-Supplied Vaccine Program

Healthcare providers can enroll in the program to order vaccine for both pediatric and adult patients. Enrollment must be completed online annually and healthcare providers must agree to the terms and conditions of the program.

Know about requirements

Providers who participate in the State-Supplied Vaccine Program must agree to the program's terms and conditions and adhere to certain requirements for ordering, storing, and reporting on vaccines.

Before administering any vaccine, healthcare providers must give the current Vaccine Information Statement to patients (or their parents or guardians). This must be documented in the patient's medical record.

Know about patient eligibility

Influenza vaccine

State-supplied influenza vaccine can be provided to all children (younger than 19 years of age). It can also be provided to all adult Rhode Island residents. For Medicare Fee-For-Service patients, healthcare providers can either:

Order influenza vaccine for their Medicare Fee-For-Service patients privately, or

Order and reimburse the Department of Health for the purchase of influenza vaccine for Medicare Fee-For-Service patients.

Medicare Fee-For-Service patients are patients with straight or original Medicare. This policy does not apply to individuals with a Medicare Advantage plan or supplemental plan (through HMO or PPO). (more)

See below for a Fluzone High-Dose influenza vaccine recommenation for patients who are 65 years of age and older.

Non-influenza vaccine

Non-influenza state-supplied vaccine can be provided to all children (younger than 19 years of age). Adult, insured Rhode Island residents and adults who are non-Rhode Island residents but who are covered by a Rhode Island employer’s health plan are also eligible for non-influenza state-supplied vaccine if they are:

Medical Orders for Life Sustaining Treatment (MOLST)
are instructions to follow a terminally ill patient’s wishes regarding resuscitation, feeding tubes and other life-sustaining medical treatments. The MOLST form can be used to refuse or request treatments and are completely voluntary on the part of patients. These orders can supplement Do Not Resuscitate (DNR) instructions or a COMFORT ONE bracelet. more

A physician, registered nurse practitioner, advanced practice registered nurse or physician assistant who is authorized by the patient is authorized to sign Medical Orders for Life Sustaining Treatment.

Treat a patient in accordance with the patient's MOLST form, even if the healthcare provider who signed the MOLST order is not on staff at a facility.

Ensure a patient's Medical Orders for Life Sustaining Treatment are transferred with the patient if he/she is transferred to another healthcare provider.

If a new terminally ill patient comes under your care, you should ask about the existence of a MOLST form from the patient and/or the facility that is transferring the patient.

Review the Medical Orders for Life Sustaining Treatment on admission and ensure that the orders reflect the patient’s current wishes.

If the terminally ill patient does not have Medical Orders for Life Sustaining Treatment, you should offer them the opportunity to complete a form on admission to a nursing home, assisted living facility, home health agency, hospice program, kidney dialysis center, or hospital.

Document if a terminally ill patient does not file Medical Orders for Life Sustaining Treatment and explain the consequences of making no decision to the patient or their recognized healthcare decision maker. If there are no limitations on care, except as otherwise provided by law, cardiopulmonary resuscitation will be attempted and other treatments will be given. If a choice regarding cardiopulmonary resuscitation (CPR) is not made, cardiopulmonary resuscitation will be attempted using all available treatment options.

Void the Medical Orders for Life Sustaining Treatment if requested by your patient. To do this draw a diagonal line through the sheet, write “VOID” in large letters across the page, and sign and date below the line. Keep the voided MOLST form in the patient’s active or archived medical record, as appropriate.

Follow the most recent version of the Medical Orders for Life Sustaining Treatment if more than one form is found in the medical records.

What Medical Practices Should Do

Store patient’s medical records for at least five years after the most recent patient encounter, regardless of whether the patient is alive or dead. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. more

Provide copies when requested. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. Records should be provided within 30 days.

Make sure that records are still available if the practice is closed.

Use Electronic Health Records which provide better way to see long term medical issues and track trends among groups of people. Healthcare providers who accept medicaid or medicare must meet "meaningful use" standards. more

When prescribing opioid medications for patients, it is important that both the healthcare provider and the patient be aware of their responsibilities in prescribing and using these medications. An opioid treatment agreement between patient and provider will clarify expectations.

Definitions

Acute Pain- expected duration less than 5 days

Episodic/Procedural pain (varies depending on procedure, generally less than 30 days, after 30 days treat like chronic pain)

Chronic pain – duration of pain more than 30 days

What Healthcare Prescribers Should Do

Take a Medical History and Physical Examination: This includes an assessment of the pain, physical and psychological function, substance abuse history, assessment of underlying or coexisting diseases or conditions, and should also include the presence of a recognized medical indication for the use of a controlled substance.

Make a Treatment Plan : The treatment plan should state objectives by which treatment success can be evaluated, such as pain relief and/or improved physical and psychosocial function, and indicate if any further diagnostic evaluations or other treatments are planned. The prescriber should tailor drug therapy to the individual medical needs of each patient. Several treatment modalities or a rehabilitation program may be necessary if the pain has differing etiologies or is associated with physical and psychosocial impairment.

Prescribe Proportionately: Only prescribe the amount of pain medicine reasonably expected to be needed. If you expect 3 days of severe pain prescribe only 3 days worth of medication. Acute Pain (< 5days) can often be managed without opioids.

Start an Opioid trial: Advise your patient to try the medication for a specified period of time and re-assess. Agree that if are not making reasonable progress, to consider stopping and trying a different approach.

Obtain Informed Consent : The prescriber should discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative. This discussion should be documented and signed by the patient, guardian or authorized representative. sample

Enter Into a Prescriber-Patient Agreement : The agreement will help you and your patient share information about medications and comply with controlled substance regulations.

Co-prescribe Naloxone : If your patient is at-risk for overdose.

Monitor your patients opioid utilization : Use the Prescription Monitoring Program before each appointment. EnrollLogin Additionally, it is important to conduct random urine drug screens as well as have patients bring back pill bottles to monitor supply remaining.

Periodically Review Treatment : The prescriber should periodically review the course of opioid treatment of the patient and any new information about the etiology of the pain. Continuation or modification of opioid therapy depends on the prescriber's evaluation of progress toward treatment objectives. If the patient has not improved, the prescriber should assess the appropriateness of continued opioid treatment or trial of other modalities.

Make Consultations : The prescriber should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. In addition, prescribers should give special attention to those pain patients who are at risk for misusing their medications including those whose living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse requires extra care, monitoring, documentation and consultation with addiction medicine specialists, and may entail the use of agreements between the provider and the patient that specify the rules for medication use and consequences for misuse.

Keep Accurate Records : The prescriber should keep accurate and complete records according to items 1-5 above, including the medical history and physical examination, other evaluations and consultations, treatment plan objectives, informed consent, treatments, medications, agreements with the patient, and periodic reviews.

Be Compliant with Controlled Substances Laws & Regulations : To prescribe controlled substances, the prescriber must be licensed appropriately in Rhode Island, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions. Physicians Manual of the U.S. Drug Enforcement Administration.

Addiction is a disease, chronic and relapsing. Patients with any chronic disease deserve appropriate treatment. There are many places to find treatment for addiction and substance abuse. partial list.

Provider News

Continuing Medical Education (CME) opportunity: This CME event will provide information to healthcare providers so that they understand the latest trends in HIV and STDs, and that they can disrupt further spread of these infections by learning best practices for interacting with patients and their sexual partners. A special emphasis will be on current approaches to working with gay/bisexual men and other patients at highest risk of HIV and STDs. Participants will be provided with tools and resources to implement in their practices. This CME event will be held Thursday, April 30, 2015, from 5:15-7:30 pm at the Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI.

Hydrocodone, an opioid-type medication, will be reclassified as a Schedule II medication effective October 6, 2014. In the opinion of many regulators, patient advocates, and pain management experts, this change is long overdue.
Hydrocodone and all its combinations collectively represented the most popular pain medication prescribed in Rhode Island. Vicodin is a common brand name that contains hydrocodone. A review of 2013 data reveals there were more than 22.6 million doses filled. Schedule II medications have stricter regulation, reflective of the increased risk these medications have.
A summary of some of the rules surrounding all schedule II medications:
• The prescription must be written and signed by the prescriber.
• The prescription cannot have refills.
• The prescription is not valid after 90 days from the date it was written.
• A verbal prescription is allowed only in emergency situations and a written prescription must follow within seven days. (The pharmacist will notify the Drug Enforcement Agency if a written prescription is not received.)
• Faxed, original prescriptions are only allowed for:
o Home infusion/IV pain therapy
o Long-term-care facilities
o Hospice/terminally-ill patient
• Prescriptions have the following quantity limitations:
o 30-day supply
o Practitioners may write up to three separate prescriptions (each for up to a one-month supply) and each prescription must be signed and dated on the date they were originally written. In addition, the practitioner must write the earliest date each of those subsequent prescriptions may be filled, with directions to the pharmacist to fill no earlier than the date specified on the face of the prescription.
These are not all the rules surrounding hydrocodone and its varying combinations; however, prescribers will be responsible for following all of the rules when prescribing hydrocodone.
HEALTH urges all prescribers to plan for these changes that will take effect next week. It is likely this will have a significant impact on office practices as schedule II prescriptions cannot be phoned in to a pharmacy. HEALTH encourages e-Prescribing of Schedule II medications for safety and security.
The prescription drug abuse epidemic persists. All prescribers should consult HEALTH's website for expectations regarding responsible prescribing as well as enroll in and utilize the information found in the Prescription Monitoring Program before prescribing a controlled substance.

The U.S. Food and Drug Administration is notifying health care professionals and consumers about safety concerns with all sterile-use drug products made and distributed by Downing Labs LLC, doing business as NuVision Pharmacy, in Dallas Texas. Because NuVision Pharmacy is licensed in Rhode Island as a non-resident compounding pharmacy, the Rhode Island Department of Health is alerting physicians and patients who may have received a product from Downing Labs LLC or NuVision Pharmacy that these medications should not be taken.
"We are exercising due diligence in respect to NuVision/Downing Labs. We are unaware of any immediate threat to Rhode Islanders but people should be aware if they have medication from NuVision/Downing Labs," said Michael Fine, MD, Director of the Rhode Island Department of Health. "NuVision Pharmacy has assured us that they will not ship any medication to Rhode Island until the issue is resolved with the FDA and that they have not shipped into Rhode Island since before January 2014."
Until further notice, health care professionals should not prescribe, administer or dispense any NuVision/Downing Labs sterile products for their patients because the firm cannot ensure the safety or quality of these products. Administration of a non-sterile drug product may result in serious and potentially life-threatening infection or death.
The FDA has issued a formal request to Downing Labs for the immediate recall of all lots of its purportedly sterile products currently on the market that are not expired. In the letter, the FDA outlined poor conditions and practices identified by FDA investigators during a July 2014 inspection of Downing Labs' Dallas facility. In the letter, the FDA outlined the practices and facility conditions that raise concerns about the sterility assurance of purportedly sterile drug products made at the Downing Labs facility.
"Patient safety is our top priority. We recommend health care professionals stop prescribing sterile drugs from Downing Labs because they pose serious potential risks to patients," said Janet Woodcock, M.D., director of the FDA's Center for Drug Evaluation and Research. "Patients deserve medications that are safe, effective, and of high quality no matter who makes them, and the FDA will continue to take action to protect patients."
The FDA's recent inspection of the Downing Labs facility in Texas revealed sterility failures in 19 lots of drug products intended to be sterile, endotoxin failures in three lots of drug products, and inadequate or no investigation of these failures. Endotoxins are substances found in certain bacteria that cause a wide variety of serious reactions such as fever, shock, and changes in blood pressure and in other circulatory functions.
On July 18, 2014, the FDA alerted health care professionals not to use purportedly sterile drugs from NuVision/Downing Labs due to possible contamination. On July 26, 2013, after observing poor conditions and practices during a March – April 2013 inspection, the FDA formally requested NuVision Pharmacy recall all sterile use drug products. The FDA reminds health care professionals to check their medical supplies, and quarantine any purportedly sterile drug products prepared at the Downing Labs/NuVision's facility, and not administer them to patients.
Products made at the Downing Labs facility are distributed nationwide. Most of the product labels include: NuVision Pharmacy, Dallas Texas 75244. 1-800-914-7435. Patients who have received any drug product produced at the Downing Labs/NuVision facility and have concerns should contact their health care professional and may contact the Rhode Island Department of Health at (401)-222-5960.
The FDA is not aware of recent reports of illness associated with the use of these products. The FDA asks health care providers and consumers to report adverse reactions or quality problems experienced with the use of any products made at the Downing Labs facility to the FDA's MedWatch Adverse Event Reporting program by:
· completing and submitting the report online at www.fda.gov/medwatch/report.html; or
· downloading and completing the form, then submitting it via fax to 1-800-FDA-0178.
The FDA, an agency within the U.S. Department of Health and Human Services, protects public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation's food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

Help us ensure that expecting parents have the most up-to-date information by providing them with the "What You Need to Know Before you Have Your Baby" brochure. This brochure introduces expecting moms and dads to the blood and hearing screenings their newborns will receive before they leave the hospital. It also provides information on KIDSNET and on support available to families through Rhode Island's First Connections home visiting program. The updated brochure should replace any earlier versions you may still have in your office.

The Rhode Island Department of Health and Rutgers Global Tuberculosis Institute have opened registration for this continuing education conference on tuberculosis (TB) epidemiology, contact investigations, infection control, diagnosis, and treatment. The event is scheduled for Tuesday, September 23, 2014 (1 p.m - 8:30 p.m) at the Providence Marriott Downtown, Providence, RI. Continuing education credits are available for physicians and nurses. See complete brochure in the adjoining link for details.To register, visit http://www.eventbrite.com/e/rhode-island-tb-update-tickets-11793684227. For assistance, send an email to Rajita Bhavaraju at bhavarrr@rutgers.edu.

Director of Health Michael Fine, M.D. announced today that influenza is no longer widespread in Rhode Island. Licensed healthcare facilities' healthcare workers who had not been vaccinated against influenza had been required to wear surgical masks when engaged in direct patient contact since April 17, 2014, when the Rhode Island Department of Health (HEALTH) declared influenza to be widespread. This requirement is no longer in place. However, if the level of influenza in Rhode Island rises again, HEALTH will put the masking requirement back into effect.

Director of Health Michael Fine, MD declared today that influenza is widespread again in Rhode Island. This declaration triggers the requirement that healthcare workers who have not been vaccinated against the flu wear surgical masks during direct patient contact. The masking requirement will stay in place until the declaration of widespread influenza has been lifted.

Infectious Disease News

The United States is currently experiencing a large, multi-state outbreak of measles. Between January 1, 2015, and February 6, 2015, 121 cases from 17 states had been reported. One hundred three of these cases are linked to potential exposure at Disneyland Resort Theme Park in California. All Rhode Island healthcare providers should remain vigilant for possible measles cases. A single case of measles will trigger a full outbreak response.

Background: A 19-year-old Providence College (PC) student experienced the onset of symptoms of meningococcal meningitis on January 31 and was admitted to a Boston-area hospital. Tests confirmed that the student had meningococcal meningitis. The meningitis strain was reported to be serogroup B today. The student is recovering. A second, 20-year-old Providence College student was taken to a hospital yesterday (February 5) with purpura fulminans, altered mental status and nuchal rigidity thus meeting case definition criteria as a probable case of meningococcemia, pending lab confirmation. The two cases did not have any direct interaction with each other. Two cases occurring in this manner satisfy the CDC case criteria for an "organization-based" outbreak...

On Monday, Feb. 2, 2015, the Rhode Island Department of Health received a report of a confirmed case of meningococcal meningitis in a vaccinated Providence College student. The student was admitted to a Boston-area hospital and is reportedly improving.

Continuing Medical Education (CME) opportunity: This CME event will provide information to healthcare providers so that they understand the latest trends in HIV and STDs, and that they can disrupt further spread of these infections by learning best practices for interacting with patients and their sexual partners. A special emphasis will be on current approaches to working with gay/bisexual men and other patients at highest risk of HIV and STDs. Participants will be provided with tools and resources to implement in their practices. This CME event will be held Thursday, April 30, 2015, from 5:15-7:30 pm at the Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI.

CME Credit: This training is approved for up to 1.5 Category 1 ACCME continuing education hours/nursing education hours. This training is approved for up to 1.5 Category 1 ACCME continuing education hours/nursing education hours.
Target Audience: This training is intended for health care professionals who diagnose and treat tuberculosis. This training opportunity is available to a national audience.
Description: This 75-minute presentation will be followed by a 15-minute Q and A session. In recent years a number of rapid molecular diagnostics for detecting tuberculosis as well as drug resistance have become available both commercially and in public health labs. This webinar will describe the different NAATs (nucleic acid amplification tests) that are available to you, including the Gen-Probe MTD test, the Xpert MTB/RIF test, and Pyrosequencing (PSQ), as well as rapid molecular tests for drug resistance, including PSQ, line probe assays, and the CDC MDDR Service. We will describe what NAATs can and cannot tell you and how to best use these tests for AFB smear positive and smear negative clinical specimens. The webinar will also discuss the interpretation of specific mutations and drug resistance.

CDC is reminding clinicians of the benefits of influenza antiviral medications and urging continued influenza vaccination of unvaccinated patients this influenza season. Because of the detection of drifted influenza A (H3N2) viruses, this CDC Health Advisory is being issued to re-emphasize the importance of the use of neuraminidase inhibitor antiviral medications when indicated for treatment and prevention of influenza, as an adjunct to vaccination.

The following (CDCHAN-00373) was distributed via the CDC Health Alert Network on November 25, 2014, 13:45 ET (1:45 PM ET)...
Summary:
The Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and Connecticut Departments of Public Health and Consumer Protection are investigating a fatal case of gastrointestinal (GI) mucormycosis caused by Rhizopus oryzae in a premature infant. The infant received ABC Dophilus® Powder, a dietary supplement product containing viable microbial ingredients purchased from Solgar, Inc., Leonia, New Jersey. The product claimed to have "probiotic" properties and is marketed for infants and children. Subsequent testing of the same lot of unopened Solgar ABC Dophilus® Powder revealed contamination with Rhizopus oryzae. The purpose of this HAN advisory is to provide awareness about this fatal case of GI mucormycosis following ingestion of a contaminated dietary supplement and to provide guidance to state health departments and health care providers. Please disseminate this information to healthcare workers in neonatal intensive care units, hospital pharmacies, pediatricians, and primary care providers, as well as to microbiology and pathology laboratories.

Immunization News

The U.S. Food and Drug Administration recently approved Gardasil 9 (Human Papillomavirus 9-valent Vaccine, Recombinant) for the prevention of certain diseases caused by nine types of Human Papillomavirus (HPV). However, Gardasil 9 has not been approved by the Centers for Disease Control and Prevention (CDC)'s Advisory Committee on Immunization Practices (ACIP) and Gardasil 9 is not currently commercially available. Rhode Island healthcare providers should continue vaccinating patients against HPV with the currently available quadrivalent Gardasil vaccine. It is unknown when Gardasil 9 will become commercially available, so deferring vaccination in anticipation of its availability is discouraged. The Rhode Island Department of Health (HEALTH) will provide updates to healthcare providers about Gardasil 9 as they are made by the manufacturer and the CDC.

Given that the midpoint of the 2014-2015 influenza season has passed, providers of state-supplied influenza vaccine may begin to receive doses with expiration dates that are approaching. This is especially true of Live Attenuated Influenza Vaccine [LAIV] (FluMist). Providers should consider making smaller and more frequent orders (weekly). Much of the FluMist currently being shipped will expire in February and March. Some doses, however, will expire at the end of January.

12/23/2014 10:17 EST

Reporting doses during blackout

During the vaccine ordering and shipping blackout periods, healthcare providers will still be able to submit doses-administered reports. (Healthcare providers are unable to order vaccine from 12/16 through 1/1/2015. Vaccine shipments will resume after the blackout period. Deliveries will be arriving the week of 1/5/2015.)

11/06/2014 10:57 EST

Vaccine ordering and delivery blackout periods

Healthcare providers will not be able to order vaccine from 12/16 through 12/29. Vaccine will not be shipped to healthcare providers from 12/19 through 1/5. Orders of influenza vaccine must be placed between 12/9 and 12/15 for delivery before the blackout begins. These orders should be for 3-weeks supply. monthly orders of non-influenza must be placed no later than 12/10 to guarantee delivery before the shipping blackout begins.
Providers who have monthly orders scheduled between 11/15 and 12/10 should order enough vaccine for 90 days. This is enough vaccine to get through this blackout period, plus 30 additional days.
Providers who have monthly orders scheduled between 12/11 and 12/31 should contact Mark Francesconi or Viviana Ciccia before 12/5 to have their order date changed to 12/10. These orders should be normal 60-day supply requests.
Mark Francesconi (Mark.Francesconi@health.ri.gov | 401-222-5988); Viviana Ciccia (Viviana.Ciccia@health.ri.gov | 401-222-4639)

11/06/2014 10:56 EST

Fourtec Help Desk

If you contact Fourtec and do not receive a reply within two business days (Mon-Thurs), email Mark Francesconi (Mark.Francesconi@health.ri.gov). Please give a detailed description of your issue in your email. Fourtec is the company that provides technical support for the Rhode Island Department of Health's data loggers.